Predicting the receipt of employer-sponsored health insurance: the role of residence and other personal and workplace characteristics

Employment-Based Health Insurance: Analysis of Rural-Urban Differences in One State

This study estimates the propensity of firms to offer health insurance in a simultaneous equation model to control for the endogeneity between wages and health insurance. Previous research finds differences in rural and urban employer behavior with respect to health insurance benefits fully explained by differences in wages and firm size. In contrast, this study finds residual unexplained differences in the propensity to offer coverage that may be attributable to differences in plan supply, plan distribution, or differences in availability of substitutes for coverage (safety net care). Rural worker participation in offered coverage is more responsive to wage level than is the participation decision of urban workers. Together, these results imply that some of the differences in health insurance coverage rates for rural workers could be amenable to policy interventions.

Physician Perceptions of Practice Environment and Professional Satisfaction in California: From Urban to Rural

CONTEXT

Few studies have systematically examined the experience of rural practice from the physician's perspective or included physicians from an array of specialties, particularly non-primary care.

PURPOSE

To better understand differences between rural and urban physicians in perceptions of their practice environment.

METHODS

In 2001-2002, self-administered questionnaires were sent to a probability sample of primary care and specialist physicians identified from the American Medical Association's Physician masterfile in California. Logistic regression was performed to model the effect practice location had on key variables, controlling for physician demographics, specialty, and the insurance profile of the physician's patients.

FINDINGS

Completed questionnaires were obtained from 1,365 of 2,240 eligible urban physicians (61%), and 398 of 632 rural physicians (63%). Among primary care physicians, those in rural areas defined as nonadjacent or small non-metropolitan counties were the least likely to report pressures to see more patients, limit referrals, and limit treatment options. In contrast, among specialists, those in rural areas within metropolitan areas (or in large adjacent non-metropolitan counties) were more likely than urban specialists to report practice pressures. Although rural physicians in both primary care and specialist fields were more likely than urban physicians to report difficulty attracting new physicians to their communities, they perceived their overall practice climate to be better. Physicians in the nonadjacent-or-small non-metropolitan category were the most satisfied, but specialists in the nonadjacent-or-small non-metropolitan category were the least satisfied.

CONCLUSION

Physicians in rural California appear to have maintained a greater sense of clinical autonomy and higher professional satisfaction compared with their urban counterparts.

Rural-Urban Differences in Employment-Related Health Insurance

CONTEXT

Rural residents are disproportionately represented among the uninsured in the United States.

PURPOSE

We compared nonelderly adult residents in 3 types of nonmetropolitan areas with metropolitan workers to evaluate which characteristics contribute to lack of employment-related insurance. RESEARCH DESIGN AND ANALYSIS: Data were obtained from the Medical Expenditure Panel Survey, pooled across 3 panels (1996--1998) to enhance the rural sample size. Econometric decomposition was used to quantify the contribution of employment structure to differences in the probability of being offered employment-related health insurance.

FINDINGS

The most rural workers are 10.4 percentage points less likely to be offered insurance compared with urban workers; the difference is smaller for residents of other rural areas. In rural counties not adjacent to urban areas, lower wages and smaller employers each account for about one-third of the total difference.

CONCLUSIONS

Health insurance disparities associated with rural residence are related to the structure of employment. Major factors include smaller employers, lower wages, greater prevalence of self-employment, and sociodemographic characteristics.

Use, quality, and outcomes of care for mental health: the rural perspective

This review synthesizes empirical research in rural mental health services to identify current research priorities to improve the mental health of rural Americans. Using a conceptual framework of the multiple determinants of use, quality, and outcomes, the authors address (1) how key constructs are operationalized, (2) their theoretical influence on the care process, (3) reported differences for nonmetropolitan and metropolitan individuals or within nonmetropolitan individuals, (4) salient issues rural advocates have raised, and (5) key research questions. While the authors recognize that rurality is a useful political umbrella to organize advocacy efforts, they propose that investigators no longer employ any of the multiple definitions of the term in the literature as even intrarural comparisons have not provided compelling evidence about the underlying causes of observed outcomes differences. Until these underlying causes have been identified, it is difficult to determine which components of the nonmetropolitan service system need to be improved.

Developing policies responsive to barriers to health care among rural residents: what do we need to know?

A substantial body of research has been devoted to the subject of access to health care services for rural residents, much with the intention of shaping government policies to remove barriers or equalize the distribution of health care services. A number of programs and policies have grown out of or been affected by access research, yet despite identifiable successes of the policy research process, barriers to health care services still exist in rural areas. This article attempts to stimulate discussion about ways that rural health researchers can build on past research on access to care. A framework for posing access questions is proposed, suggesting that access research focus on the following areas: factors that drive differences in utilization, availability, and acceptability; consumer satisfaction and an understanding of why rural consumer satisfaction has been found to be high; factors that impede access that are mutable; and services that can be shown to improve outcomes.

Changes in health insurance coverage within rural and urban environments--1977 to 1987

This study examines changes in the health insurance coverage of the nonelderly population in rural and urban areas between 1977 and 1987, using data from the National Medical Care Expenditure Survey (NMCES) and the National Medical Expenditure Survey (NMES). It was designed to test the hypothesis that differences in the rates of health insurance coverage in rural and urban areas have diminished over time, and to explore the composition of changes in coverage within rural and urban environments. The data suggest that the proportions of the populations that are without health insurance in rural and urban areas have converged since 1977. Although both rural and urban settings witnessed increases in the proportion of their populations without health insurance from any source, urban regions experienced a greater increase than did rural areas. These changes occurred among most subgroups within the population. In no subgroup did the percentage of the population without insurance in urban areas exceed that found in rural areas in either 1977 or 1987.

Urban and rural differences in health insurance and access to care

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies. Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P < 0.01). These differences were confirmed by multivariate analysis. Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.

Urban-rural differences in employer-based health insurance coverage of workers

Prior research indicates that rural workers are less likely than urban workers to obtain health insurance coverage through their employer. The reasons for this differential in coverage rates are not well understood. This study uses data from the 1993 Robert Wood Johnson Foundation Employer Health Insurance Survey to measure differences in the proportion of rural and urban workers who are offered insurance coverage and in their rates of participation in offered plans, and to assess the effects of firm size, wages, and other factors in explaining the residential differences. Both offer rates and participation rates are lower in rural areas, but the probability of employer-based coverage among rural workers rises to the level of that of urban workers when we adjust rural firm size and wages to urban levels. Rural firms and workers are not behaviorally different from urban firms and workers; they are, however, at a greater disadvantage because of their smaller size and lower wages.